The author refers to the RACP CFS guidelines (1997), which are not only at least five years out of date and incomplete, but biased to a psychological model of CFS. Also, the CFS criteria (Fukuda 1994) used for research case definitions is "vague, over-inclusive and has poor diagnostic reliability" (Journal of Chronic Fatigue Syndrome 2000; 7:17-22).

The US State of the Science Conference on CFS held last October also acknowledged the need for CFS patient populations to be sub-grouped/stratified when it comes to research and management.

All of the cognitive behaviour therapy studies to date ignore the above facts, and even modify the criteria used. Cognitive behaviour therapy (and supportive therapy) is a useful tool, but it does not treat the underlying (as yet unidentified) disease processes in CFS.

The "Jenny" case in the article says it all. I showed it to my GP colleagues who quickly diagnosed her as suffering from depression. The alcohol abuse alone gives it away. Even one of my CFS patients (with no psychiatric disorder after being assessed by two psychiatrists) recognised the depression in "Jenny". My patients reminded me that most CFS patients actually become intolerant to alcohol.

New research in neuroimaging (SPECT ant PET) shows significant, localised reductions in blood flow to areas of the limbic system and brain stem regions. The areas affected are different from those seen in patients with depression. Research also indicates that CFS patients are no more de-conditioned than sedentary controls. Most can undertake a rigorous exercise test in a lab, but the next day (usually 24 hours later) many are bedridden, and we don't know why.

There is clearly a core group of "classic" CFS patients who have chronic fatigue easily exacerbated with minimal physical or mental effort, neuro-cognitive dysfunction, myalgia (especially in the initial stages), plus or minus orthostatic intolerance symptoms. Those who develop depressive symptoms invariably have reactive depressions.

Fortunately, most GPs have access to good management guidelines and patient information on self-care from CFS support groups.

Dr Peter Del Fante
Adelaide, SA

Editor's note: The RACP CFS guidelines referred to above were the latest at the time the article was written. The RACP currently has a second draft of these guidelines out for comment but they are yet to be finalised.